Early resumption of antiplatelet therapy (APT) and anticoagulant therapy (ACT) ≤7 days after gastrointestinal bleeding (GIB) offers a favourable benefit–risk balance in patients with cardiovascular (CV) or cerebrovascular indications, according to a systematic review and meta-analysis conducted by researchers from the Chinese University of Hong Kong and Nanyang Technological University in Singapore.
“GIB complicates antithrombotic therapy in 2.5–10 percent of patients annually, yet evidence-based guidance on optimal resumption timing remains limited,” the researchers wrote. [Clin Gastroenterol Hepatol 2020;18:337-346.e19; Clin Gastroenterol Hepatol 2026;doi:10.1016/j.cgh.2026.07.002]
“Resumption of APT and/or ACT after GIB in patients with CV or cerebrovascular indications is a complicated decision. The nature of these conditions and their associated risk of major vascular events and mortality are key determinants,” they continued.
They therefore conducted a meta-analysis to address this clinical dilemma by quantifying the risks and benefits of resumption vs discontinuation of antithrombotic therapy after GIB, and by providing exploratory pooled evidence on the impact of timing of antithrombotic therapy resumption in terms of recurrent GIB, major vascular events, and all-cause mortality.
Among 21 studies included, 85 percent were retrospective cohorts, 52 percent were conducted in North America, 38 percent were conducted in Europe, and 19 percent were conducted in Asia. The participants’ mean age was 63–79 years, and 44–71 percent were male.
APT resumption following GIB was associated with a 30 percent reduction in risk of major vascular events (hazard ratio [HR], 0.70; 95 percent confidence interval [CI], 0.60–0.83; absolute risk difference [ARD], -3.6 percent), a 56 percent reduction in risk of mortality (HR, 0.44; 95 percent CI, 0.26–0.76; ARD, -10 percent), and a 42 percent increased risk of recurrent GIB (HR, 1.42; 95 percent CI, 1.09–1.84; ARD, +2.2 percent).
ACT resumption was associated with a 55 percent reduction in risk of major vascular events (HR, 0.45; 95 percent CI, 0.34–0.58; ARD, -7 percent), a 47 percent reduction in risk of mortality (HR, 0.53; 95 percent CI, 0.43–0.65; ARD, -11.1 percent), and a 59 percent increased risk of recurrent GIB (HR, 1.59; 95 percent CI, 1.38–1.83; ARD, +2.6 percent).
Temporal analysis revealed that the increase in risk of recurrent GIB peaked at 79 percent within the first year after antithrombotic therapy resumption, and subsequently declined over time to 38 percent at 5 years.
“In contrast, CV protection and mortality benefits were sustained throughout follow-up, indicating that long-term net clinical benefit remains substantially positive,” the researchers highlighted.
Specifically, the risk of major vascular event was reduced by 57 percent at ≤1 year and 45 percent at ≤5 years after antithrombotic therapy resumption, whereas the risk of all-cause mortality showed consistent reductions of 48–51 percent across ≤3 months, ≤1 year and ≤5 years.
Notably, compared with delayed resumption at >7 days, early resumption of antithrombotic therapy at ≤7 days was associated with a 61 percent reduction in risk of major vascular events (HR, 0.39; 95 percent CI, 0.19–0.78; ARD, -11.4 percent), a 49 percent increase in risk of recurrent GIB (HR, 1.49; 95 percent CI, 1.18–1.89; ARD, +2.7 percent), and no significant difference in mortality risk (HR, 0.78; 95 percent CI, 0.29–2.10; ARD, -4.7 percent).
“In patients with CV or cerebrovascular conditions requiring APT or ACT, these medications should be resumed as early as possible after the acute episode of GIB is under control,” the researchers concluded.